nursing students and older people nursing - Doria

NURSING STUDENTS AND OLDER PEOPLE NURSING Towards a future career Sanna Koskinen

TURUN YLIOPISTON JULKAISUJA – ANNALES UNIVERSITATIS TURKUENSIS Sarja - ser. D osa - tom. 1224 | Medica - Odontologica | Turku 2016

University of Turku Faculty of Medicine Department of Nursing Science Doctoral Programme in Nursing Science

Supervised by Professor Helena Leino-Kilpi, RN, PhD, FEANS Department of Nursing Science University of Turku and Turku University Hospital Turku, Finland

Docent Leena Salminen, PHN, PhD Department of Nursing Science University of Turku Turku, Finland

Reviewed by Docent Anja Rantanen, RN, PhD School of Health Sciences University of Tampere Tampere, Finland

Docent Seija Muurinen, RN, PhD Department of General Practice and Primary Health Care University of Helsinki Helsinki, Finland

Opponent Professor Helen Allan, RN, PhD School of Health and Education Middlesex University London London, United Kingdom

The originality of this thesis has been checked in accordance with the University of Turku quality assurance system using the Turnitin OriginalityCheck service.

ISBN 978-951-29-6437-6 (PRINT) ISBN 978-951-29-6438-3 (PDF) ISSN 0355-9483 (Print) ISSN 2343-3213 (Online) Painosalama Oy - Turku, Finland 2016

To Juha

   

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Abstract

Sanna Koskinen NURSING STUDENTS AND OLDER PEOPLE NURSING – TOWARDS A FUTURE CAREER Department of Nursing Science, Faculty of Medicine, University of Turku, Finland Annales Universitatis Turkuensis, Painosalama Oy, Turku 2016

ABSTRACT The purpose of this two-phased study is to examine the interest of nursing students in choosing a career in older people nursing. First, the scoping phase explores the different premises for choosing older people nursing as a career. Second, the evaluation phase investigates the outcomes of the developed educational intervention involving older people as promoters of choosing a career in older people nursing, factors related to these outcomes, and experiences with educational intervention. The ultimate goal is to encourage more nursing students to choose older people nursing as their career. The scoping phase applies an exploratory design and centres around a descriptive, crosssectional survey, documentary research and a scoping literature review. The information sources for this phase include 183 nursing students, 101 newspaper articles and 66 research articles. The evaluation phase applies a quasi-experimental design and a pre-post-test design with a non-equivalent comparison group and a post-intervention survey. The information sources for this phase include 87 nursing students and 43 older people. In both phases, statistical and narrative methods are applied in the data analysis. Nursing students neutrally regarded the idea of a career in older people nursing. The most consistent factors related to the nursing students’ career plans in older people nursing were found to be nursing work experience and various educational preparations in the field. Nursing students in the intervention group (n=40) were more interested in older people nursing and had more positive attitudes towards older people than did students in the comparison group (n=36). However, in both groups, the interest that students had at the baseline was associated with the interest at the one-month follow-up. There were no significant differences between the groups in terms of the students’ knowledge levels about ageing. The nursing students and older people alike highly appreciated participating in the educational intervention. It seems possible to positively impact nursing students and their choices to pursue careers in older people nursing, at least in the short-term. The involvement of older people as promoters of this career choice provides one encouraging alternative for impacting students’ career choices, but additional research is needed. Keywords: nursing students, older people, nursing, career, education, involvement

Tiivistelmä

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Sanna Koskinen SAIRAANHOITAJAOPISKELIJAT JA IÄKKÄIDEN HOITOTYÖ – KOHTI TULEVAISUUDEN TYÖURAA Hoitotieteen laitos, lääketieteellinen tiedekunta, Turun yliopisto, Suomi Annales Universitatis Turkuensis, Painosalama Oy, Turku 2016

TIIVISTELMÄ Tämän kaksivaiheisen tutkimuksen tarkoituksena oli selvittää sairaanhoitajaopiskelijoiden kiinnostusta iäkkäiden hoitotyöhön uravalintana. Ensimmäisessä vaiheessa analysoitiin iäkkäiden hoitotyön uravalinnan lähtökohtia. Toisessa vaiheessa arvioitiin tätä tutkimusta varten kehitetyn iäkkäiden hoitotyön uravalinnan edistämiseen tarkoitetun koulutusintervention (Learning with Older People Programme LOPP) tuloksia ja siihen yhteydessä olevia tekijöitä sekä kokemuksia koulutusinterventiosta. Koulutusintervention keskeisenä elementtinä oli iäkkäiden henkilöiden osallistuminen interventioon. Tutkimuksen tavoitteena on edistää useampien sairaanhoitajaopiskelijoiden kohdalla iäkkäiden hoitotyön valitsemista työuraksi.  Selvitysvaiheen kuvailevassa tutkimusasetelmassa hyödynnettiin poikkileikkauskyselyä, dokumenttianalyysiä ja kirjallisuuskatsausta. Tutkimusaineiston muodostivat 183 sairaanhoitajaopiskelijaa, 101 sanomalehtiartikkelia ja 66 tutkimusartikkelia. Arviointivaiheen puolikokeellisessa tutkimusasetelmassa hyödynnettiin interventio- ja vertailuryhmien ennenjälkeen-mittauksia ja intervention jälkeistä kyselyä. Tutkimusaineiston muodostivat 87 sairaanhoitajaopiskelijaa ja 43 iäkästä henkilöä. Molemmissa vaiheissa käytettiin sekä tilastollisia että narratiivisia analyysimenetelmiä. Sairaanhoitajaopiskelijoiden kiinnostus iäkkäiden hoitotyöhön urana oli neutraalia. Keskeisimmät kiinnostukseen yhteydessä olevat tekijät olivat työkokemus hoitotyöstä ja erilaiset ratkaisut iäkkäiden hoitotyön koulutuksessa. Interventioryhmän opiskelijat (n=40) olivat kiinnostuneempia iäkkäiden hoitotyöstä ja heillä oli myönteisemmät asenteet iäkkäitä henkilöitä kohtaan kuin vertailuryhmän opiskelijoilla (n=36). Molemmissa ryhmissä opiskelijoiden kiinnostus iäkkäiden hoitotyöhön ennen opintojaksoa (ennen-mittaus) oli yhteydessä kiinnostukseen kuukauden kuluttua opintojakson päättymisestä (jälkeen-mittaus). Ryhmien välillä ei ollut eroja ikääntymistä koskevassa tiedon tasossa. Sekä opiskelijat että iäkkäät henkilöt kokivat osallistumisen koulutusinterventioon erittäin myönteisenä. Koulutuksella on mahdollista vaikuttaa sairaanhoitajaopiskelijoiden kiinnostukseen iäkkäiden hoitotyöhön uravalintana myönteisesti ainakin lyhytaikaisesti. Iäkkäiden henkilöiden osallistuminen iäkkäiden hoitotyön koulutukseen ja sitä kautta iäkkäiden hoitotyön uravalinnan edistämiseen tarjoaa yhden rohkaisevan vaihtoehdon vaikuttaa sairaanhoitajaopiskelijoiden uravalintaan. Aiheesta tarvitaan kuitenkin lisätutkimusta. Avainsanat: sairaanhoitajaopiskelija, iäkkäät ihmiset, hoitotyö, ura, koulutus, osallisuus

   

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Table of Contents

TABLE OF CONTENTS ABSTRACT ............................................................................................................................. 4  TIIVISTELMÄ ........................................................................................................................ 5  LIST OF FIGURES AND TABLES ...................................................................................... 8  LIST OF ABBREVIATIONS ................................................................................................. 9  LIST OF ORIGINAL PUBLICATIONS ............................................................................ 10  1.  INTRODUCTION ........................................................................................................... 11  2.  LITERATURE REVIEW ............................................................................................... 13  2.1. Career choices of nursing and nursing education ....................................................... 13 2.2. Older people as promoters of a career choice in older people nursing and nursing education ..................................................................................................................... 17 2.3. Gaps in the knowledge of current literature ................................................................ 22 3.  PURPOSE OF THE STUDY AND RESEARCH QUESTIONS ................................. 23  4.  MATERIALS AND METHODS .................................................................................... 25  4.1. Study designs, participants and data collection .......................................................... 26 4.1.1. Scoping phase (I, II, III) ................................................................................... 26 4.1.2. Evaluation phase (IV, V, Summary) ................................................................ 27 4.2. Implementation of standard teaching and the intervention ......................................... 30 4.2.1. Standard teaching ............................................................................................. 30 4.2.2. Learning with Older People Programme (LOPP)............................................. 30 4.3. Instruments .................................................................................................................. 33 4.4. Data analysis ............................................................................................................... 37 4.5. Ethical considerations ................................................................................................. 38 5.  RESULTS ......................................................................................................................... 42  5.1. Premises for nursing students’ choice of a career in older people nursing ................. 42 5.1.1. Nursing students’ interest in older people nursing (I) ...................................... 42 5.1.2. Finnish society’s attitudes towards older people (II)........................................ 42 5.1.3. Main research areas in the education of older people nursing (III) .................. 43 5.2. Nursing students’ choice of a career in older people nursing ..................................... 44 5.2.1. Outcomes of the Learning with Older People Programme (IV) ....................... 46 5.2.2. Factors related to the outcomes ........................................................................ 48 5.2.3. Experiences of the Learning with Older People Programme (V) ..................... 53 5.3. Summary of the results ............................................................................................... 56 6.  DISCUSSION ................................................................................................................... 57  6.1. Discussion of the results ............................................................................................. 57 6.2. Validity and reliability of the study ............................................................................ 60 6.2.1. Validity and reliability of the data collection ................................................... 60 6.2.2. Validity and reliability of the instruments ........................................................ 61 6.2.3. Validity of the results ....................................................................................... 64 6.3. Suggestions for future research ................................................................................... 66 6.4. Practical implications .................................................................................................. 67

Table of Contents

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7.  CONCLUSIONS .............................................................................................................. 69  8.  ACKNOWLEDGEMENTS ............................................................................................ 70  9.  REFERENCES ................................................................................................................ 72  ORIGINAL PUBLICATIONS I‒V ..................................................................................... 79 

   

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List of Figures and Tables

LIST OF FIGURES AND TABLES Figure 1. Design of the study ................................................................................................. 24  Figure 2. Flow chart of the sub-study IV (2014) and its measurement design (modified from Koskinen et al. 2016) ..................................................................................... 29  Figure 3. Main research areas in the education of OPN (III) ................................................ 43  Figure 4. Findings of the sub-study V ................................................................................... 55  Figure 5. Summary of the results ........................................................................................... 56 

Table 1. Background factors of nursing students related to choosing career in OPN .......... 17  Table 2. Study sample, setting, time, design, data collection and analysis in five substudies (I‒V, Summary) ......................................................................................... 25  Table 3. Outline of the Learning with Older People Programme (LOPP) (modified from Koskinen et al. 2016) ............................................................................................. 32  Table 4. Structure and statements of the Students’ Interest in Nursing Older People Scale (SINOPS) ............................................................................................................... 35  Table 5. Summary of the statistical procedures used in different phases of the study ......... 38  Table 6. Descriptive statistics in students’ categorical background variables and group differences at the baseline (M0) ............................................................................. 44  Table 7. Descriptive statistics in students’ numeric background variables and group differences at the baseline (M0) ............................................................................. 45  Table 8. Differences between the IG and the CG at the baseline (M0) and follow-up (M2)47  Table 9. Relations between the independent variables and the outcomes at the baseline (M0) ........................................................................................................................ 50  Table 11. Relations between the independent variables and the outcomes at the follow-up (M2) ........................................................................................................................ 50  Table 10. Correlations between the independent variables and the outcomes at the baseline (M0) and at the follow-up (M2) ............................................................................. 51  Table 12. Independent determinants (excluding SINOPS total score) at M0 of the SINOPS total for the IG at M2.............................................................................................. 52  Table 13. Independent determinants (including SINOPS total score) at M0 of the SINOPS total for the IG at M2.............................................................................................. 53  Table 14. Background information of the older people in LOPP .......................................... 54  Table 15. Internal consistency of the instruments (Cronbach’s alpha (α) coefficients) ......... 62  Table 16. Factor loadings of SINOPS .................................................................................... 63 

List of Abbreviations

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LIST OF ABBREVIATIONS AACN

American Association of Colleges of Nursing

ANCOVA

Analysis of covariance

ANOVA

Analysis of variance

CG

Comparison group

CINAHL

Cumulative Index to Nursing and Allied Health Literature

ECTS

European Credit Transfer and Accumulation System

ERIC

Education Resource Information Center

ETENE

National Advisory Board on Social Welfare and Health Care Ethics

FAQ1

Facts on Aging Quiz

ICN

International Council of Nurses

IG

Intervention group

KAOP

Kogan’s Attitudes towards Older People scale

LOPP

Learning with Older People Programme

LPN

Licensed practical nurse

MEDLINE

Medical Literature Analysis and Retrieval System Online

OPN

Older people nursing

OSF

Official Statistics of Finland

RM-ANOVA

Repeated measures analysis of variance

RN

Registered nurse

SAS

Statistical Analysis System

SINOPS

Students’ Interest in Nursing Older People Scale

SPSS

Statistical Package for the Social Sciences

SUI

Service user involvement

TENK

Finnish Advisory Board on Research Integrity

UN

United Nations

VAS

Visual analogue scale

WHO

World Health Organization

WVI

Work Value Inventory

   

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List of Original Publications

LIST OF ORIGINAL PUBLICATIONS This thesis is based on the following publications which are referred to in the text by their Roman numerals I‒V. I

Koskinen S, Hupli M, Katajisto J & Salminen L. 2012. Graduating Finnish nurse students’ interest in gerontological nursing – A survey study. Nurse Education Today 32(4), 356‒360.

II

Koskinen S, Salminen L & Leino-Kilpi H. 2014. Media portrayals of older people as illustrated in Finnish newspapers. International Journal of Qualitative Studies on Health and Well-being 9, 25304. doi: 10.3402/qhw.v9.25304

III

Koskinen S, Salminen L, Stolt M & Leino-Kilpi H. 2015. The education received by nursing students regarding nursing older people: a scoping literature review. Scandinavian Journal of Caring Sciences 29(1), 15–29.

IV

Koskinen S, Salminen L, Puukka P & Leino-Kilpi H. 2016. Learning with older people – Outcomes of a quasi-experimental study. Nurse Education Today 37, 114‒122.

V

Koskinen S, Salminen L & Leino-Kilpi H. Learning with older people – Experiences of nursing students and older people. (Submitted)

The original publications have been reproduced with the permission of the copyright holders. The thesis also contains unpublished material.

Introduction

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1.

INTRODUCTION

Older people nursing (OPN) is one of the future careers in nursing. As one of societies’ greatest achievements, the increase in average life expectancy is resulting in fast-growing older people populations worldwide (Eurostat 2015, United Nations UN 2015). In Finland, the proportion of people over age 65 in the population is estimated to rise from the current 20% to 26% by 2030, and to 29% by 2060 (Official Statistics of Finland OSF 2015). Despite a general increase in health, a portion, especially the oldest, of this demographic lose their ability to manage independently at some point, due to chronic and degenerative diseases causing declines in physical or cognitive functioning (World Health Organization WHO 2015). In these cases, many older people turn to health and social services to receive nursing care. This increases the need of services, and thus workforce demands, in the future. In Finland, registered nurses (RN) and licensed practical nurses (LPN) are the largest staff groups that provide care for older people. Approximately 5000 RNs and, depending on the calculation method, from 25 000 to 31 000 LPNs work in municipal social services for older people (including, for instance, residential nursing care, sheltered housing and home help services). In addition, RNs and LPNs work with older people in health services such as the wards of health centres (National Institute for Health and Welfare 2015). Due to an ageing population, large numbers of nurses are expected to retire and leave the workforce during the next two decades, just when there will be higher demand for this type of work (Sherman et al. 2013, European Commission 2012). In Finland, the average age of the personnel in municipal health and social services today is just below 45. Of the personnel in 2014, about 29% will have reached the age of 65 by 2025, and it is likely that most of them will then retire. By 2030, about 43% will have reached the age of 65 (National Institute for Health and Welfare 2015). The need for an increased nursing workforce has been taken into account in the education planning in the health care sector, and the intake of students has increased (Ministry of Education and Culture 2012) to ensure that an adequate supply of skilled nursing staff will be available to provide high-quality care across settings to diverse older people populations in the future (Ministry of Social Affairs and Health 2013, Act 980/2012, International Council of Nurses ICN 2006, 1999). One of the greatest needs for this increase exists in the initial vocational health and social care education. To be able to meet the requirements of the Act (980/2012) on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons, to have a competent nurse workforce in older people services, the intake of RNs (bachelor’s degree) has also been increased (Ministry of Education and Culture 2012). The importance of nurses’ education and competence in OPN has been recognised. Several international and national policy papers and guidelines state that the competence of nurses in OPN needs to be established in undergraduate education and strengthened with continuing training. These documents regulate and recommend that nursing degree programmes should include theoretical and clinical instruction on the care of older people and geriatrics (Eriksson et al. 2015, WHO 2015, Ministry of Social Affairs and Health 2013, Directive 2013/55/EU, 2005/36/EC, ICN 2006, 1999, Ministry of Education 2006). In some countries, more detailed recommendations concerning the curricula of OPN has been established (e.g., American Association of Colleges of Nursing AACN and the Hartford Institute for Geriatric Nursing at New York University College of Nursing 2010), in terms of improving and enhancing    

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Introduction

education and training in OPN. The goal of these documents is to ensure that nursing students are able to provide the necessary care for the ageing population. The involvement of service users – all potential users of health care services – in health care education has also been encouraged internationally through increasing the emphasis on policy (Towle et al. 2010, Morgan & Jones 2009, Repper & Breeze 2007). Service user involvement (SUI) is recommended in order to bring the patient voice into education by recognising their expertise based on experience. Involvement is assumed to reduce the power imbalance between health care professionals and patients, and thus lead to improvements in health care services in terms of patient-centred care, shared decision making and the promotion of self-care (Perry et al. 2013, Towle et al. 2010, Jha et al. 2009, Morgan & Jones 2009, Repper & Breeze 2007). Similar to SUI, the active participation of older people should be recognised and enabled, according to their individual needs, preferences and capacities (WHO 2015, 2002, Ministry of Social Affairs and Health 2011). The diverse inclusion of older people − allowing them to make their voices heard within various municipal services, such as cultural, sports, education and technical services, and in other activities, – should be safeguarded (Ministry of Social Affairs and Health 2013, Act 980/2012). In this study, OPN is defined as a nursing field that aims to promote and maintain the wellbeing – or the health and functional capacity – of older people as well as provide treatment and care for the sick, frail and dying. The foundation of OPN lies in ethical principles, such as individuality and special competence, that combine multidisciplinary knowledge and teamwork (Bing-Jonsson et al. 2015, Finnish Hoidokki thesaurus 2015, Medical Subject Headings MeSH thesaurus 2015, Ministry of Social Affairs and Health 2013, National Advisory Board on Social Welfare and Health Care Ethics ETENE 2008, ICN 2006, Kelly et al. 2005). OPN is carried out in all health and social care settings where care is provided for older people. However, it is particularly exercised in settings such as long-term care in health centres, nursing homes, assisted living residences and facilities, and the homes of older people. This study focuses on nursing students and their plans of whether or not to choose OPN as their career.

Literature Review

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2.

LITERATURE REVIEW

The following chapters describe the career choices of nursing and nursing education, and explore the role older people as promoters of a career choice in OPN, based on literature. When older people act as promoters of this career choice students are provided with opportunities to learn directly from the ones they might eventually care for. Consequently, it is assumed that this may enhance student understanding of the reality and uniqueness of OPN and encourage them to consider the field as a potential career choice.

2.1. Career choices of nursing and nursing education The process of choosing a career in nursing can be examined by first defining the concept, then exploring nursing students’ reasons for entering nursing programmes, as well as factors that influence the decision to choose a career in nursing. This exploration is based on a narrative analysis of original research. The sources were identified through a systematic search carried out in the beginning of 2016, in four international electronic databases (MEDLINE, CINAHL, PsycINFO and ERIC). The terms, “nursing students” and “career choice” were used to search for relevant titles and abstracts of the citations. In addition, studies found through a manual search, for instance based on reference lists, were used to complete the review of the literature. The search was limited to publications from 1995‒2015 and to works written in English. In total, 14 studies were included. Definition of career choice Career choice in this study is defined as choosing one field of nursing over other alternatives. To choose one nursing field over another is a complex process influenced by a variety of variables, comparable to choosing a nursing career over other occupation alternatives. Career choice is a dynamic process of career construction, and requires ongoing adjustment, not just a one-time decision (Price 2009). Reasons to choose a career in nursing Students’ reasons for entering nursing programmes are both personal and career related. Personal reasons are more dominate in the decision to study nursing and include the desire to care for others and help people and the opportunity for self-development. The desire to care for others and wanting to help people are the most consistent and important reasons for students worldwide choosing a career in nursing (Başkale & Serçekuş 2015, Wilkes et al. 2015, Halperin & Mashiach-Eizenberg 2014, Tayebi et al. 2013, Usher et al. 2013, Jirwe & Rudman 2012, McLaughlin et al. 2010, Price 2009, Mooney et al. 2008, Rognstad et al. 2004, Larsen et al. 2003). Some students have viewed nursing even as their vocation and life calling and felt compelled to pursue it (Usher et al. 2013, McLaughlin et al. 2010). When students seek an opportunity for self-development (McLaughlin et al. 2010, Rognstad et al. 2004) in the nursing field, they generally have personal interest in health related issues, they want to develop professional knowledge and clinical competency (Halperin & Mashiach-Eizenberg 2014, Haron et al. 2014, Tayebi et al. 2013, Lai et al. 2008), and they regard nursing as a profession with possibilities for career advancement (McLaughlin et al. 2010, Rognstad et al. 2004). Career related reasons – job security, actual content of practising nursing, and social status – are also important in a student’s decision to enter a nursing programme. Job security, an    

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Literature Review

employee continuing in gainful employment throughout his or her working life, is among the most significant reasons for choosing nursing as a career (Wilkes et al. 2015, Usher et al. 2013, McLaughlin et al. 2010, Mooney et al. 2008, Larsen et al. 2003). Students generally regard nursing as a career with almost guaranteed employment opportunities (Başkale & Serçekuş 2015, Haron et al. 2014, Tayebi et al. 2013), and it offers at least a satisfactory income (Başkale & Serçekuş 2015, Halperin & Mashiach-Eizenberg 2014, Haron et al. 2014, McLaughlin et al. 2010, Rognstad et al. 2004). The actual content of practising nursing also attracts some to consider a career in nursing. Nursing is regarded to offer a wide range of possible work tasks, areas and settings (Haron et al. 2014, Usher et al. 2013, Jirwe & Rudman 2012, McLaughlin et al. 2010, Mooney et al. 2008, Grainger & Bolan 2006, Larsen et al. 2003). The teamwork nature of the job is also attractive to students (Halperin & Mashiach-Eizenberg 2014, McLaughlin et al. 2010). Nursing is generally regarded as a noble and respectable career path, and, although this is not the main reason for choosing this profession, its social status is valued by students (Halperin & Mashiach-Eizenberg 2014, Usher et al. 2013, Jirwe & Rudman 2012, Price 2009). Students are also drawn into the field by its academic education requirements (Wilkes et al. 2015, Tayebi et al. 2013). Factors influencing the decision to choose a career in nursing The most significant factors that can affect the decision to choose a career in nursing include the influence of other people, past personal experiences and the media. The influence of family members and friends, through their support and encouragement, is one of the most influential factors in this career choice (Başkale & Serçekuş 2015, Jirwe & Rudman 2012, McLaughlin et al. 2010, Price 2009, Mooney et al. 2008, Grainger & Bolan 2006). A family member or a friend who has worked as a nurse or another type of health care professional can provide information about nursing to potential nursing students (Usher et al. 2013, McLaughlin et al. 2010, Price 2009, Larsen et al. 2003). Similarly, other positive role models and supporters, such as nurse educators, supervisors and peers, are influential when students consider a career in nursing (McLaughlin et al. 2010, Price 2009, Lai et al. 2008). Past personal experiences also affect the career choices of students. The experience of a loved one or oneself having been ill and/or hospitalised has, at times, led students to pursue a nursing career (Haron et al. 2014, Usher et al. 2013, McLaughlin et al. 2010, Price 2009, Mooney et al. 2008, Larsen et al. 2003). Also, past experiences in nursing-related employment can positively influence a student to choose a career in nursing (Mooney et al. 2008, Larsen et al. 2003). The media is another potential factor that can influence students’ perceptions regarding a career in nursing. However, the media has only been the main factor in a few cases. Students have often already made up their minds in favour of pursing nursing training, and the publicity of the field has only confirmed their decision (Haron et al. 2014, Price 2009, Mooney et al. 2008, Larsen et al. 2003). A career choice in older people nursing The choice of a career in OPN can be further examined from the perspectives of nursing students’ career plans in the field, and their reasons for and factors related to their plans. These perspectives are described based on a narrative analysis of original research. The sources for this angle of examination, as in the previously mentioned source selection process, were identified through a systematic search carried out in the beginning of 2016, in four international electronic databases (MEDLINE, CINAHL, PsycINFO and ERIC). The search terms included

Literature Review

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“nursing students”, “older adults”, “older people”, “older patients”, “older persons”, “elderly”, “elderly patients”, “elderly people”, “aged people”, “geriatric”, “gerontological” and “career”. These terms were applied to titles and abstracts of the citations. In addition, studies found through a manual search, for instance based on reference lists, were used to complete the review of the literature. The search was limited to publications from 1995‒2015 and to works written in English. In total, 32 studies were included. Career plans regarding older people nursing Nursing students worldwide have predominantly considered a career in OPN to be among the least preferred nursing areas to pursue after graduation. This was the case during the years covered in this literature review (Rathnayake et al. 2016, Mattos et al. 2015, Birks et al. 2014, Haron et al. 2013, King et al. 2013, Xiao et al. 2013, Shen & Xiao 2012, Stevens 2011, McCann et al. 2010, Bernardini Zambrini et al. 2008, Henderson et al. 2008, Kloster et al. 2007, DeKeyser Ganz & Kahana 2006, Hweidi & Al-Obeisat 2006, Happell 2002, Burg et al. 2001, Stevens & Crouch 1995). Even so, a minority of nursing students do consider OPN as potential career alternative (Carlson & Idwall 2015, Frost et al. 2015, Gould et al. 2012, Wang et al. 2009, Lee et al. 2006). Some studies have even found that students neutrally or moderately regard a career OPN (Cheng et al. 2015, Brown et al. 2008, Lee et al. 2006). Moreover, students are often still uncertain about their intention to work with older people (McCann et al. 2010, Pan et al. 2009), although the proportion of undecided students drops significantly as graduation approaches (McCann et al. 2010). Of graduated nurses, approximately 16‒26% start working in OPN as their first job (Abrahamsen 2015, Marsland & Hickey 2003). Like OPN, psychiatric nursing has also been among the least preferred career alternatives in the nursing field, especially when students are asked at the beginning of their education, although it does see some increase in popularity by the time of graduation (Birks et al. 2014, McCann et al. 2010, Kloster et al. 2007, Happell 2002). Contrarily, among the most preferred career alternatives for the majority of nursing students, regardless of the study phase, are pediatric nursing (Birks et al. 2014, Xiao et al. 2013, Shen & Xiao 2012, Gonc¸alves et al. 2011, Stevens 2011, McCann et al. 2010, Henderson et al. 2008, Kloster et al. 2007, DeKeyser Ganz & Kahana 2006, Happell & Brooker 2001, Stevens & Crouch 1995), surgical nursing (Shen & Xiao 2012, Stevens 2011, Kloster et al. 2007, DeKeyser Ganz & Kahana 2006, Happell 2002, Stevens & Crouch 1995) and intensive or critical care nursing (King et al. 2013, Stevens 2011, Henderson et al. 2008, DeKeyser Ganz & Kahana 2006). Reasons not to choose a career in older people nursing The following paragraphs focus on the most common reasons why a career in OPN is often not chosen as a field of employment after graduation. Specifically, attention is given to the negative view of work characteristics in older people nursing, the negative image of work environments, the perceived negative effect on one’s career path, and the lack of personal interest or abilities. These reasons remained static during the time period covered in this literature review. Students considering OPN as a potential career alternative often state the reasons for their preference as being that they enjoy working with older people (Kloster et al. 2007, Lee et al. 2006) and that they consider OPN to be meaningful. Students are generally aware of the challenges in this type of nursing and want to take responsibility for solving its problems (Rathnayake et al. 2016, Kloster et al. 2007).

   

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Literature Review

The negative view of work characteristics in OPN (Gould et al. 2015, Xiao et al. 2013, Shen & Xiao 2012, Stevens 2011, Henderson et al. 2008, Kloster et al. 2007, Happell 2002, Happell & Brooker 2001, Stevens & Crouch 1995) is based on various perceptions of the job. It may be seen as lacking challenge, boring, repetitive, routine-like, or physically and/or psychologically taxing with a heavy workload (Gould et al. 2015, Rejeh et al. 2011, Kloster et al. 2007, Happell 2002, Fagerberg et al. 2000). Moreover, the negative view of this type of work can relate to the frustration that students may perceive at working with older people who do not get better. The work can be seen as sad and depressing (Happell 2002). The negative image of work environments often relates to the shortage and poor quality of resources (Xiao et al. 2013, Shen & Xiao 2012, Rejeh et al. 2011, Stevens 2011, Kloster et al. 2007, Happell & Brooker 2001, Fagerberg et al. 2000). Due to financial cutbacks, students have expressed concerned about how they would manage to work in the way they wanted and have been taught. Moreover, students have expressed a feeling of powerlessness at not always being able to influence how services and care are provided to older people (Fagerberg et al. 2000). The perception that working in OPN can negatively affect one’s career path (Gould et al. 2015, Xiao et al. 2013, Shen & Xiao 2012, Stevens 2011, Happell 2002, Happell & Brooker 2001, Fagerberg et al. 2000, Stevens & Crouch 1995) relates to the view that the prospects of a career in OPN are regarded as low (Fagerberg et al. 2000). Students have been found to think that there is less diversity of diseases and conditions in OPN than in other areas, and therefore, they would not be able to use all of their acquired knowledge and skills and would eventually forget them (e.g., how to give injections) (Gould et al. 2015, Happell 2002, Happell & Brooker 2001, Fagerberg et al. 2000). Moreover, students have expressed worries about being paid less than they would be in other nursing areas for doing more work (Xiao et al. 2013, Shen & Xiao 2012). Some students simply lack the personal interest or abilities (Xiao et al. 2013, Shen & Xiao 2012, Stevens 2011, Henderson et al. 2008, Happell & Brooker 2001, Stevens & Crouch 1995) needed to pursue a career in OPN. This relates to the fact that some students do not feel comfortable with older people (Xiao et al. 2013, Happell & Brooker 2001) or otherwise find the field ill-suited for them (Henderson et al. 2008, Happell & Brooker 2001). Some may even have a fear of dealing with dying or suffering patients (Henderson et al. 2008). Others may lack the confidence to work with older people (Xiao et al. 2013, Shen & Xiao 2012) and are unable to communicate with them (Henderson et al. 2008). Some students may be frightened of the responsibility, as it is often the case that nurses in OPN are solely in charge of patients, with no colleagues or superiors available for discussion or consultation (Fagerberg et al. 2000). Factors related to choosing a career in older people nursing Several sociodemographic, experiential and educational factors have been repeatedly examined to determine their effect on nursing students’ career plans in OPN. Table 1 provides a summary of the main factors having statistically significant connections, either positive or negative, to students’ career plans in OPN. Only two background factors seem to have a consistent relation to students’ career plans in OPN. These factors are previous experience − either personal or work-related − with older people, and students’ attitudes towards older people. Students who have had experience with and positive attitudes towards older people tend to regard a career in OPN more preferably.

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Literature Review

 

Some factors, such as age and stage of education, have either a contradictory or weak relation to students’ career plans in OPN. Regarding factors like gender and cultural or ethnic backgrounds, study samples tend to have only a limited number of male participants or students from diverse backgrounds. Therefore, it is difficult to examine these as potential factors related to career plans in the field. Table 1. Background factors of nursing students related to choosing career in OPN Background factor

Related to career in OPN +/-

Authors, publication year

Age Younger Older

++ ++

Xiao et al. 2013, Shen & Xiao 2012 Abrahamsen 2015, Gonçalves et al. 2011, Lee et al. 2006

Personal experience with older people Yes/A lot

++

Nursing work experience Yes/A lot

++++++

Stage of education Beginning Graduation Experience with studying OPN Positive

Low Attitudes towards older people Positive

Cheng et al. 2015, Henderson et al. 2008 --

+ --+++

Negative Knowledge about older people/ageing High

-

-++

-

Cheng et al. 2015, Zisberg et al. 2015, Haron et al. 2013, Xiao et al. 2013, Gonçalves et al. 2011, Stevens 2011, Henderson et al. 2008, Brown et al. 2008 Zisberg et al. 2015 Zisberg et al. 2015, Gould et al. 2012, Lee et al. 2006 Carlson & Idwall 2015, Cheng et al. 2015, Brown et al. 2008 Brown et al. 2008, Marsland & Hickey 2003 Mattos et al. 2015, Gonçalves et al. 2011, Lee et al. 2006 Lee et al. 2006

++++++++

Rathnayake et al. 2016, Cheng et al. 2015, Mattos et al. 2015, Zisberg et al. 2015, de Guzman et al. 2013, Haron et al. 2013, Gonçalves et al. 2011, Pan et al. 2009, Henderson et al. 2008, Hweidi & Al-Obeisat 2006, Burg et al. 2001 Negative --Xiao et al. 2013, Shen & Xiao 2012, Henderson et al. 2008 The symbols +/- (one symbol/study) indicate the statistically significant positive or negative connection to students’ career plans regarding OPN. The symbol + indicates positive relation to the career plans; the symbol indicates a negative relation to the career plans.

2.2. Older people as promoters of a career choice in older people nursing and nursing education Older people themselves can act as promoters of a career choice in OPN. This phenomenon is examined from two perspectives. Firstly, the concept of SUI in health care education is defined,    

18

Literature Review

and its characteristics and outcomes are described. Secondly, the educational solutions featuring the involvement of older people, in terms of visits to older people and service learning, are described. Service user involvement in health care education SUI in health care education is described based on a narrative analysis of literature reviews as well as a concept analysis. The sources were identified through a systematic search carried out in the beginning of 2016, in four international electronic databases (MEDLINE, CINAHL, PsycINFO and ERIC) by applying the search terms to the titles of the citations. The search terms included “patient and public involvement”, “patient participation”, “consumer participation”, “user involvement”, “patient involvement”, “consumer involvement”, and “education”, and were used to search titles of the citations. The search was limited review-type publications from 1995‒2015 that had been written in English. In total, nine reviews and one concept analysis were included. Definition of service user involvement in health care education Service user involvement in health care education in this study is defined as a teaching and learning strategy in which the lived experiences of health care users are utilised in the education of students aiming to become health care professionals. As seen in the search terms listed above, there are many other applicable terms to name this process (Towle et al. 2010). With these in mind, the term service user can refer to a variety of people, including healthy people, people with health problems and their lay caregivers, that is as anyone with direct experience of health and social care services (Scammell et al. 2016, Towle et al. 2010). The dictionary definition of involvement is “the fact or condition of being involved with or participating in something” (MOT Oxford Dictionary of English). Characteristics of service user involvement in health care education SUI in health care education is different from SUI in direct care and in research. In education, it refers to the situation in which people – most commonly those from seldomly heard groups who often have the most need to be heard (Rhodes 2012, Le Var 2002) – are engaged because of their expertise and experiences of health, illness or disability. In these situations, the service users are aware that they have designated roles. SUI in health care education does not refer to simulated patients (or standardised patients or patient instructors) who act as real patients, simulating a set of symptoms or problems they do not actually have, in order to create an educational situation (Towle et al. 2010, Terry 2012). Moreover, involvement in education is characterised by signifying genuine collaboration between service users and nursing education staff (Rhodes 2012, Le Var 2002). SUI in health care education can occur in a number of ways, from design and development of the course, to student selection, direct teaching, assessment of students, and research (Scammell et al. 2016, Rhodes 2012). Service users have often played the role of teachers or teaching aids in classrooms (Happell et al. 2014, Terry 2012, Jha et al. 2009, Morgan & Jones 2009, Repper & Breeze 2007). Service users consistently prioritise the need for training in interpersonal skills over ‘technical’ skills (Repper & Breeze 2007). Therefore, the most common teaching and learning strategies employed in classrooms include service users’ personal stories and students being required to demonstrate awareness of user perspectives in case study presentations (Terry 2012). Less often, service users participate in assessment or curriculum development, course

Literature Review

19

 

advisory committees, producing learning materials, and teaching students on clinical placements (Scammell et al. 2016, Happell et al. 2014, Jha et al. 2009, Morgan & Jones 2009, Repper & Breeze 2007). Outcomes of service user involvement in health care education Students’ perceptions of SUI in their own education have been generally positive and acceptable, regarded as adding value in their education (Scammell et al. 2016, Happell et al. 2014, Perry et al. 2013, Towle et al. 2010, Morgan & Jones 2009, Repper & Breeze 2007, Le Var 2002). SUI gives students the opportunity to learn directly from service users (Terry 2012, Towle et al. 2010). Students are able to gain insight into the perspectives of service users and demonstrate a more empathic understanding of the needs of vulnerable populations (e.g., people with mental illness) and their care (Scammell et al. 2016, Happell et al. 2014, Perry et al. 2013, Towle et al. 2010, Morgan & Jones 2009, Repper & Breeze 2007, Le Var 2002). As a consequence, students’ assumptions and attitudes may improve significantly, which may help to ensure relevant care provision (Jha et al. 2009). Students can learn to be more holistic and person-centred in the manner in which they practise nursing (Perry et al. 2013, Rhodes 2012, Terry 2012, Morgan & Jones 2009, Le Var 2002). Specifically, students exposed to SUI tend to demonstrate better interpersonal and communication skills (Perry et al. 2013, Repper & Breeze 2007), they are able to more accurately identify clients’ needs, and they develop better assessment skills (Terry 2012) as well as physical examination skills (Towle et al. 2010). Service users themselves also benefit from the involvement in health care education. The reported specific therapeutic benefits include raising self-esteem and feelings of empowerment, increasing confidence and self-worth, gaining new insights into their problems, and expanding their knowledge. Service users also enjoy the companionship of students and generally feel well-treated by students (Scammell et al. 2016, Towle et al. 2010, Morgan & Jones 2009, Repper & Breeze 2007). Educational solutions featuring the involvement of older people Educational solutions featuring the involvement of older people are described based on a narrative analysis of original research. The sources were identified through a systematic search carried out in the beginning of 2016, in four international electronic databases (MEDLINE, CINAHL, PsychINFO and ERIC). The search terms were applied to the titles and the abstracts of the citations, and included “nursing students”, “elderly”, “older people”, “older person”, “older adult”, “aged”, “intervention”, “program”, “learning”, “course”, “curriculum”, “module”, “session”, “seminar”, “presentation”, “education”, “training”, and “teaching”. In total, 17 studies were included. The educational solutions featuring the involvement of older people were visits to older people and service learning. Visits to older people Visits to older people have been the most common educational solution involving older people themselves. In these visits, nursing students have been individually or in small groups, paired with a certain older person for a pre-determined period of time (Eaton 2015, Reitmeier et al. 2015, Walton & Blossom 2013, Basran et al. 2012, Lamet et al. 2011, Chen & Walsh 2009, Walsh et al. 2008, Ryan et al. 2007). Typically, these visits have spanned from about one month (Chen & Walsh 2009, Walsh et al. 2008) or one semester (Eaton 2015, Walton & Blossom 2013, Basran et al. 2012), up to a whole academic year (Ryan et al. 2007). Students have been    

20

Literature Review

expected to visit their older person four (Eaton 2015, Walton & Blossom 2013, Basran et al. 2012, Chen & Walsh 2009, Walsh et al. 2008) to ten times (Reitmeier et al. 2015, Ryan et al. 2007), depending on how long the sequential visits were to last. Single visits usually have taken about one hour (Reitmeier et al. 2015, Chen & Walsh 2009, Walsh et al. 2008). Visits have taken place either in the homes of community-dwelling older people (Walton & Blossom 2013, Basran et al. 2012, Chen & Walsh 2009, Walsh et al. 2008, Ryan et al. 2007) or in assisted living facilities (Eaton 2015, Reitmeier et al. 2015). The most common activity that students have been required to carry out during their visit has been to conduct an interview with the older person. Students have been given a list of questions or themes, most often concerned with the older person’s general life-history, living situation, and significant life events, as well as changes in the world over their life span. Students have also inquired about the older person’s knowledge of available community resources for older people, their partner’s knowledge about their medications, nutrition, and physical activities, and their latelife potential (Eaton 2015, Reitmeier et al. 2015, Walton & Blossom 2013, Basran et al. 2012). Some of the visits have been informally organised in various environments, and students and older people have even met for dinner or at a party, either at the nursing school (Basran et al. 2012) or at the community senior centres (Chen & Walsh 2009). In addition to interviewing and discussing with older people, students have created art (Lamet et al. 2011, Chen & Walsh 2009, Walsh et al. 2008) or an ethnodrama – a form of theatre – with older people. Other elements, such as introductory lecturing, written learning assignments and summarising reflective discussions, have also been combined with the visits. Before the visits, students have received 1‒2 hours of instructions for interviewing and regarding communication with older people, as well as lectures about old age (Lamet et al. 2011, Chen & Walsh 2009, Walsh et al. 2008, Ryan et al. 2007). Most often students have written structured reflective journals regarding their experiences with older people (Eaton 2015, Reitmeier et al. 2015, Walton & Blossom 2013, Basran et al. 2012, Ryan et al. 2007). Moreover, students have also been invited to share their experiences among peers during or after the visits, in group discussions moderated by their instructors (Eaton 2015, Reitmeier et al. 2015, Basran et al. 2012, Chen & Walsh 2009). The outcomes of the visits with older people are unsound because of the nature of how single studies have reported on a variety of visits. However, there are slight indications that these sequential visits may improve students’ attitudes towards older people as well as help sustain existing positive attitudes (Basran et al. 2012, Lamet et al. 2011, Ryan et al. 2007). When it comes to changes in attitudes though, there is a question of whether creating art with older people during the visits is what improves students’ attitudes or the improvement comes from simply interviewing older people (Walsh et al. 2008, Chen & Walsh 2009). Based on a single study, visiting alone has not had an effect student willingness to work with older people (Lamet et al. 2011). Students have been highly satisfied with and have appreciated the visits and found them enjoyable (Reitmaier et al. 2015, Basran et al. 2012, Lamet et al. 2011, Walsh et al. 2008). Students have valued their relationships with older people and also demonstrated understanding of generational experiences that define the human experience and the impact of this uniqueness on the nursing care profession (Eaton 2015, Reitmaier et al. 2015, Walton & Blossom 2013). Moreover, students have reported that they have learned more about older people than they would have in traditional education, and that they have improved their knowledge of geriatrics, community resources for older people, and how to communicate with older people (Walton & Blossom 2013, Basran et al. 2012).

Literature Review

21

 

Service learning Service learning is commonly used, especially in the United States, to learn about ageing issues and OPN. Service learning is a teaching strategy that incorporates organised service activities in meeting the needs of an identified community, while reinforcing course content and providing an opportunity for applied learning experience and reflection. These communitybased, mainly out-of-classroom experiences, carried out in places like senior citizen centres or older people’s homes, are especially intended to develop students’ views on the value of service to individuals and vulnerable populations, such as older people (Beauvais et al. 2015, Lai et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Leung et al. 2012, Davis et al. 2008). Service learning and similar solutions, usually covered midway through clinical training in nursing practice and academic education, mainly include the same forms and activities as the aforementioned visits to older people. The service learning initiatives have commonly started with an introductory lecture or a workshop as a classroom session, which has focused on the aims of service, assignments and activities expected to be completed, and issues related to ageing (Lai et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Leung et al. 2012, Shellman 2006, 2007). The service itself has often involved visiting and interviewing older people, conducting health assessments and nursing plans for them, creating artwork and participating in recreational activities with them, or reminiscencing with them (Beauvais et al. 2015, Lai et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Gallagher & Carey 2012, Leung et al. 2012, Davis et al. 2008, Shellman 2007, 2006). The duration of total service has varied from approximately 10 to 20 hours, at 1‒2 hours per week over a 6‒13 week period (Beauvais et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Leung et al. 2012, Shellman 2007, 2006). Students have also visited the same older person three or four times each consecutive semester over a year and a half (Davis et al. 2008) or even up to two years (Lai et al. 2015). During the service, there has often been a tutoring instructor who has facilitated the interactions and the activities between students and older people (Beauvais et al. 2015, Lai et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Davis et al. 2008, Shellman 2007, 2006). The service has been supported by learning activities such as reflective writings, collecting a learning portfolio and self-studying of materials in the course management system. The reflective, intergenerational discussions during and after the service have been core activities of service learning (Beauvais et al. 2015, Lai et al. 2015, Hwang et al. 2014, Hwang et al. 2013, Leung et al. 2012, Davis et al. 2008, Shellman 2006, 2007). The outcomes of service learning and other, similar solutions are very limited by the small number of relevant studies. When compared to students who had not participated in service learning activities, those who did demonstrated higher levels of cultural self-efficacy (Shellman 2007) and felt more competent in areas specific to geriatric assessment (e.g., nutritional status, depression, sleep problems, polypharmacy) (Davis et al. 2008). Their overall knowledge of ageing and their understanding of mental health needs in old age increased, and their negative attitudes toward older adults decreased, although the effect was not long-lasting (Leung et al. 2012). Similarly, although no significant differences were found between groups, the attitudes of students who had attended service learning did improve (Beauvais et al. 2015, Hwang et al. 2014, Hwang et al. 2013), as did their knowledge about older people (Beauvais et al. 2015). Students reported that they had learnt about the worldviews and cultural perspectives of older people, and thus were better prepared to care for them (Shellman 2006). Students also expressed appreciation for the opportunity to acquire social skills in caring and communication (Lai et al. 2015, Hwang et al. 2014).    

22

Literature Review

2.3. Gaps in the knowledge of current literature Previous literature concerning the career choice of nursing students in OPN has focused on surveying students about their plans to work in the field after graduation and the various factors associated with these plans. There is a limited number of follow-up studies examining how the career plans of students change over the education period and how students realise those plans after graduation, when they move into working life. Similarly, there is very limited information available on specific interventions aiming to effect the career choices of students in OPN. Although the previous educational solutions have assigned a role to older people in nursing education, this role has often been rather implicit and even passive. The older people have acted as respondents to pre-determined questions or as the subject of a geriatric assessment. To sum up, there is limited evidence supporting the relationship between the involvement of older people and the career choices of nursing students in OPN. Based on the literature review, nursing students’ career plans regarding OPN as well the reasons not to choose a career in OPN were investigated in terms of the interest of nursing students in OPN, and this was the main outcome of this study. For the secondary outcomes, factors related to choosing a career in OPN were studied by exploring the attitudes of nursing students towards older people. Moreover, because various educational solutions have been created to develop knowledgeable nursing students for OPN, knowledge levels about ageing were examined also as a secondary outcome.

Purpose of the Study and Research Questions

23

 

3.

PURPOSE OF THE STUDY AND RESEARCH QUESTIONS

The purpose of this study is to examine the interest of nursing students in choosing OPN as a career. This study has two phases: the scoping phase and the evaluation phase (Figure 1). In the first phase, different premises for choosing older people nursing as a career were explored. In the second phase, the outcomes of the developed educational intervention, and factors related to the outcomes, were evaluated, along with the experiences of the participants in the educational intervention. The ultimate goal of this study is to encourage more nursing students to choose older people nursing as their career. More specifically, the research questions addressed are as follows: Scoping phase: Premises for nursing students to choose a career in older people nursing 1. What are the premises for nursing students to choose OPN as a career? 1.1 What is nursing students’ interest in OPN? 1.2 What are the attitudes of society towards older people in Finland? 1.3 What are the main research areas in the field of nursing education pertaining to OPN? Evaluation phase: Nursing students’ choice of a career in older people nursing 2. What are the outcomes of the developed educational intervention involving older people (Learning with Older People Programme LOPP)? 3. What factors are related to the outcomes of the educational intervention? 4. What significant experiences result from the educational intervention? 4.1 What are the experiences of older people during their active role in the educational intervention? 4.2 What are the experiences of nursing students during the educational intervention involving older people? The following hypotheses (H) for the evaluation phase are proposed: Students in the intervention group (IG) H1: are more interested in OPN, H2: have more positive attitudes towards older people, and H3: have higher knowledge levels about ageing than students in the comparison group (CG).

   

24

Purpose of the Study and Research Questions

DEMAND FOR COMPETENT NURSES IN OLDER PEOPLE NURSING

1.1 research question Questionnaire survey – Reality premise Sub-study I

SCOPING PHASE 2012‒2013 1. research question 1.2 research question Document analysis – Societal premise Sub-study II

1.3 research question Scoping literature review – Scientific premise Sub-study III

DEVELOPMENT OF THE EDUCATIONAL INTERVENTION (LOPP)

2. research question

EVALUATION PHASE 2014‒2015 3. research question

Quasi-experimental study: Pre-post-test comparison group design Sub-study IV

Summary

4. research question 4.1 research 4.2 research question question Quasi-experimental study:

Post-intervention survey Sub-study V

NURSING STUDENTS HAVE A POSITIVE APPROACH TO OPN AS A CAREER

Figure 1. Design of the study

25

Materials and Methods

 

4.

MATERIALS AND METHODS

The answers to the research questions are based on various materials and methods (Table 2). Table 2. Study sample, setting, time, design, data collection and analysis in five sub-studies (I‒V, Summary) Phase

Sub-study I

II

Scoping

Sample, setting, time Graduating bachelor’s degree nursing students (n=183), three polytechnics in Southern Finland, 2009 Newspaper articles (n=101), three Finnish daily newspapers, three months in 2012

Design

Data collection

Data analysis

Cross-sectional survey

Questionnaire: background questions and instrument (later called SINOPS) developed for this study Article selection from Helsingin Sanomat, Aamulehti and Turun Sanomat following the sampling strategy Systematic searches from MEDLINE, CINAHL and ERIC, selection of articles following the inclusion and exclusion criteria Questionnaire: background questions including WVI, SINOPS, KAOP, FAQ1 instruments

Descriptive statistics, t-test for independent samples, Spearman r

Documentary research/document analysis

III

Research articles (n=66), three international electronic databases, 2013

Scoping literature review

IV, summary

Nursing students in the middle of their bachelor’s degree studies(n=87), two Finnish polytechnics geographically separate, 2014

Quasiexperimental prepost-test design

V

Nursing students (n=46), older people (n=47), two polytechnics, 2014

Post-intervention survey

Evaluation

Questionnaire: open and structured questions developed for this study

Thematic analysis, quantification

Qualitative content analysis, quantification

Descriptive statistics, ChiSquare, Fisher’s exact test, t-tests for independent and paired samples, RMANOVA, ANCOVA, Pearsson/Spearman r, multivariate linear modeling Descriptive statistics, qualitative content analysis

   

26

Materials and Methods

4.1. Study designs, participants and data collection 4.1.1. Scoping phase (I, II, III) The overall design of the scoping phase was exploratory. In terms of data sources, the aim was to investigate the nature of those premises potentially related to nursing students’ interest in OPN (Polit & Beck 2008). In Finland, polytechnic schools, as institutions of higher education, are responsible for bachelor level education of RNs (Ministry of Education and Culture 2016). Nursing degree programmes in Finland follow the European Union directives (Directive 2005/36/EC and 2013/55/EU) as well as national guidelines and recommendations (Eriksson et al. 2015, Ministry of Education 2006). Nursing degree studies generally consist of 210 study points, according to the European Credit Transfer and Accumulation System (ECTS). This equates to 3.5 years of full-time study. Based on Finnish legislation (Act 932/2014), polytechnics have the autonomy to decide on their own nursing degree curriculum, including how training for OPN is carried out. Therefore, education regarding OPN varies depending on the polytechnic. A similar situation has been recognised internationally, where the education regarding OPN can also vary considerably within one country (Lahtinen et al. 2014, Deschodt et al. 2010, Gilje et al. 2007). A descriptive, cross-sectional survey design (I) was used to chart nursing students’ interest in OPN. Data were collected in 2009 from three purposefully selected polytechnics of different sizes in the Southern Finland. A convenience sample (N=254) of graduating nursing students were invited to take a part in this study. Data were collected with a structured paper-and-pencil questionnaire. In two polytechnics, the researcher herself distributed the questionnaires to students, and they either returned them directly to the researcher, an appointed contact person at the polytechnic, or they left the questionnaires in a designated box at their school. At one of the polytechnics the contact people distributed the questionnaires and return envelopes to the students and the students returned the questionnaires by post. The overall response rate was 72% (n=183). A documentary research design (II) was used to obtain information concerning Finnish society’s attitudes towards older people in a feasible, cost-effective and time-efficient way: instead of data collection, data selection was required. Over the course of three months in 2012, data were collected from the three main Finnish daily newspapers: Helsingin Sanomat, Aamulehti, and Turun Sanomat (MediaAuditFinland 2011). The selection of newspaper articles for analysis was based on the sampling strategy of applying the inclusion criteria (Miller & Alvarado 2005) by one researcher in the first phase and by two researchers in the second phase. Finally, 101 articles were selected for the analysis. A scoping literature review design (III) was used to map the relevant nursing education literature, in terms of the volume, nature and characteristics of the primary research, by including various study designs (Armstrong et al. 2011, Levac et al. 2010, Arksey & O’Malley 2005). A systematic search was performed in three electronic databases in 2013: MEDLINE, CINAHL and ERIC. These searches were limited to studies published in English between 1999 and 2012. Two researchers independently examined abstracts in the first phase and full texts in the second phase, and selected studies by applying inclusion criteria. Finally, a total of 66 studies were included in the review.

Materials and Methods

27

 

4.1.2. Evaluation phase (IV, V, Summary) The overall design of the evaluation phase was quasi-experimental. The aim was to establish causal connections between the intervention and outcomes. As a characteristic of a quasiexperimental design, there was no randomisation (Polit & Beck 2008, Eccles et al. 2003). To evaluate outcomes of the developed intervention, a pre-post-test design with a non-equivalent comparison group was used (IV). In addition, to examine the experiences of the nursing students and older people, regarding their participation in the intervention, a post-intervention survey was conducted for the IG (V). The evaluation phase was carried out at two different polytechnics located in geographically different areas. These polytechnics were invited to take a part in the study because their curricula concerning OPN corresponded with the focus of this study in both polytechnics, theoretical courses on OPN were offered midway through the nursing degree programme. A convenience sample of nursing students (N=87) in the middle of their studies and enrolled in compulsory theoretical OPN courses were invited to take part in the study (Figure 2). In both polytechnics, there were an IG and CG. The achieved sample size was regarded as satisfactory − by including more polytechnics, additional uncontrolled confounding factors would have arisen due to differences in curricula and other characteristics of the schools. Moreover, as the intervention was being carried out for the first time, it was challenging to predict the potential risks and difficulties that may arise, so unnecessary arrangements concerning polytechnics and students were avoided (Billingham et al. 2013). The formation of the IG and the CG in both polytechnics followed existing parallel classes. The IG and the CG participated separately in similar theoretical OPN courses, which ran parallel. Thus, there was no interaction between the IG and CG within the theoretical courses. The IG participated in the intervention before the theoretical OPN course and the CG only attended the theoretical course. Data were collected using a structured paper-and-pencil questionnaire. The researcher herself recruited the students to participate in the study and distributed the questionnaires to students during class time. The baseline (M0) data of the students in the IG were collected the morning before the first day of intervention, and the first post-test (M1) data were collected right after the intervention (Figure 2). For the students in the CG, the baseline (M0) data were collected during the first class of the theoretical course. The one-month follow-up (M2), post-test data from both groups were collected during the last class of the theoretical course. Two post-test data collections were conducted for the IGs: M1) the first was conducted immediately following LOPP to ascertain the immediate single effect of LOPP and, similar to the CGs, M2) a second measurement was conducted after one month to ascertain the joint effect of LOPP and the theoretical course. For the purpose of this study, it was deemed appropriate to collect post-test data at two points in time from the IG, in order to be able to make possible causal inferences. Data collection times held after one week (M1) and one month (M2) were regarded as frequent enough and close enough together to accurately know the causal sequence (Morrison 2009). Since the CG students received no intervention other than the standard teaching (theoretical course), no M1 measurement was obtained. It was assumed that the introductory lessons that the CG students had attended during the first week of the theoretical course would not have had an effect yet, and thus, were not considered worthwhile to examine.

   

28

Materials and Methods

Students returned the questionnaires directly to the researcher. A reminder letter and questionnaire were sent by post to students who had been absent, including a prepaid return envelope. The response rate in the baseline was 100%. The post-test response rate after onemonth’s time was 87% (n=40) for the students in the IG and 88% (n=36) for the students in the CG. Altogether, 47 ordinary, community dwelling older people without any predetermined qualifications, volunteered to participate in the intervention (Figure 2). The participants were required to be at least 70 years old, able to give informed consent and communicate verbally, and in overall good enough health. The researcher recruited older people from the local pensioner and patient organisations and via various community contacts. In the recruitment, it was clarified that the intervention was a part of a research study. It was emphasised that participation was voluntary and that it was possible to only participate in the intervention and not answer the questionnaire about the participation experiences. At the end of each day, there was time reserved for the researcher to once more tell about the study and give out written information letters and the short paper-and-pencil questionnaires to the older people. Those who volunteered to participate had the opportunity to fill in the questionnaire at that time and return it right away in a sealed envelope to the researcher. Alternatively, participants were provided with a prepaid return envelope, and could choose to complete the questionnaire at home and send it to the researcher by post. Older people who participated in the intervention for several days were requested to answer the questionnaire only after their last day of participation. The overall response rate was 92% (n=43).

29

Materials and Methods

 

ELIGIBLE NURSING STUDENTS IN TWO POLYTECHNICS N=87

INTERVENTION GROUP students N=46, n=46 school 1 students N=25 (older people n=33) school 2 students N=21 (older people n=14)

COMPARISON GROUP students N=41, n=41 school 1 students N=21 school 2 students N=20

− − − −

LOPP INTERVENTION GROUP students n=46 (older people n=47)

− − −

THEORETICAL OLDER PEOPLE NURSING COURSE

THEORETICAL OLDER PEOPLE NURSING COURSE

INTERVENTION GROUP students n=40 school 1 students n=22 > missing data n=3 school 2 students n=18 > missing data n=3

COMPARISON GROUP students n=36 school 1 students n=20 > missing data n=1 school 2 students n=16 > missing data n=4

− − −

BASELINE (M0; for the IG before LOPP, for the CG before theoretical course) Background questions including WVI SINOPS KAOP FAQ1 (Essay, not reported in the thesis)

MEASUREMENT 1 (M1; after 1 week, only for the IG) SINOPS KAOP FAQ1

MEASUREMENT 2 (M2; after 1 month) SINOPS KAOP FAQ1 (Essay, not reported in the thesis)

Figure 2. Flow chart of the sub-study IV (2014) and its measurement design (modified from Koskinen et al. 2016)

   

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Materials and Methods

4.2. Implementation of standard teaching and the intervention 4.2.1. Standard teaching In this study, standard teaching is regarded to be a compulsory, three ECTS theoretical OPN course lasting one month at both polytechnics. The learning objectives for the courses dealt with ethical action, health promotion, decision-making, guidance, cooperation, development and management, multicultural nursing, societal activity, clinical nursing and medication. The courses consisted of lectures, divided into short segments, which aimed to involve students in well-crafted, in-depth questions and discussions. Throughout the course, active lectures were supported by self-study and students were provided with materials on the learning management system. In both polytechnics, students were assessed similarly, given final grades from 1 (Sufficient) to 5 (Excellent). 4.2.2. Learning with Older People Programme (LOPP) The Learning with Older People Programme (LOPP) was developed to promote nursing students' understanding of ageing, older people and OPN and to increase their interest in OPN. LOPP was designed by the researcher for this study based on the results of the scoping phase, the evidence from the previous literature (see, for example, section 2.2) as well as the national and international policies and agendas (WHO 2015, 2002, Ministry of Social Affairs and Health 2011). The content of LOPP, the materials and the activating methods were validated by four nurse educators, experienced in teaching OPN, from the participating polytechnics, two from each polytechnic. Two meetings were arranged, one in each polytechnic, in which the researcher requested nurse educators to freely give feedback on how well the objective set for LOPP had been met that week. Based on their feedback, only fine-tuning adjustments were made to the programme. The intervention was carried out similar way at both polytechnics. LOPP draws on the experiences of people in the community over the age of 70. This age was set because it was considered that people of this age have more likely experienced some consequences of ageing and changes in their role in society than those who had just retired at age 65 (WHO 2015). No upper age limit was set for participation. LOPP focused on healthy people, as they would probably be more likely to improve students’ views than if students were exposed to fragile older people in poor condition (Chonody 2015, Tullo et al. 2010, Schwartz & Simmons 2001). This decision was also made because LOPP was being implemented and tested for the first time. LOPP was carried out in the polytechnic setting. This setting is regarded as an environment where students are allowed to be learners, not necessarily having mastered nursing yet, unlike expectations in clinical practice settings. In the polytechnic setting, students may feel safer and more free to ask questions. In addition, LOPP should not increase the costs related to the teaching infrastructure, and the classrooms equipped with computers and data projectors were sufficient for this programme. LOPP is delivered as intensive teaching. In this study, intensive teaching is defined as a format of teaching where the time taken to deliver the teaching is compressed into the timespan of one week. Thus, LOPP lasts for five days and consists of 27 contact lessons (equivalent to one ECTS), five to six hours daily. Although the evidence concerning the outcomes of intensive teaching is scarce, intensive teaching has demonstrable advantages overall when compared to

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the ‘traditional’ formats of one and a half-hour-long lectures during semester-long courses. The benefits of intensive teaching can include increased motivation, commitment and concentration, diversity of teaching methods, stimulation and enthusiasm, stronger relations among students and flexibility for both students and instructors. (Davies 2006.) Similarly, it was assumed that by concentrating solely on lessons involving older people, it would be possible to deepen the relationships between the students and the older people, and as such, to improve deep-level learning and understanding. These benefits were regarded to outweigh the concerns that longer educational interventions are more likely to lead attitudinal changes (Tullo et al. 2010). Moreover, from the feasibility point of view, knowing that nursing curricula are often full and that it is difficult to include any new content related to OPN (AlSenany & AlSaif 2014, Deschodt et al. 2010, Gilje et al. 2007), a one-week programme was regarded as a realistic way to implement this content into existing curricula. In addition, five to six hours of daily participation is regarded as the maximum time length that older people can manage. It was assumed that longer days would result in less quality interaction, if older people, as well as students, became tired. The goal when selecting the content for LOPP was to introduce content to which the older people could easily relate, based on their experiential knowledge. Because of this, complex medical information and detailed clinical information relating to nursing procedures was left out. The content of LOPP emphasised the health promotion and well-being of older people and diverse nursing care for older people. The selection of the topics for the content was based on several sources, including the main principles of the nursing curricula for older people at the two participating polytechnics, the previous literature (see, for example, section 2.2) and the national and international policies and agendas. Concretely, students and older people worked together daily in small groups on various topics. There were approximately five students and two older people per group, and most of the time the groups worked on their own. After a short orientation and introduction held by the researcher, the activating methods referred to in the previous literature (see, for example, section 2.2) were applied to promote the exchange of thoughts and stimulate further discussion in small groups (Table 3). The tasks of older people were to discuss with the students and participate in the daily learning assignments. For the discussions, the older people were anticipated to, for instance, share personal health data and reflect on life events and their experience of aging. For the learning assignments, older people were expected to, for instance, take part in the exercises and games and pose for photographs.

   

Day 1 – Monday Day 2 – Tuesday Day 3 – Wednesday Day 4 – Thursday Day 5 – Friday 6 lessons* 6 lessons 5 lessons 5 lessons 5 lessons** Similarities and Health promotion for Encounters with illness, Person-centred OPN Older people differences between individually ageing older losses and death involvement in society generations people Short lectured evidence-based bulletins about the topic of the day and instructions for the day’s working groups Reflect on own Rotate to different Reflect on how falling ill Find out older people’s Chart how older people preferences, opinions and stations dealing with effects an older person’s most memorable are involved in society life events and compare nutrition, alcohol life, how close relatives experiences concerning and think how to support those with others. consumption, exercise, react, to what extent health care and the involvement of less medication, mental nurses should pay consider what to pay active people. health, conditions for attention and what are attention to in those driving, and consider the essential values in situations. how to promote healthy end-of-life care. ageing. Listing personal Reading evidence-based Writing down personal Taking a photograph Making posters using preferences (e.g., bulletins, carrying out reflections while with the student’s magazine clippings and favourite hobbies) and health assessments, watching a movie. smart phone or a coloured pencils. opinions (e.g., the most imitating physical provided tablet to important thing in life), changes when ageing, illustrate the core as well as important exercising, playing message in one public events that have games and quizzes. situation. affected one’s life. Small group presentations based on the assignments, reflective discussions of all groups together and summary of the day***

*Two lessons in the beginning of the day were used for orientating the students to LOPP by providing practical information concerning the arrangements and introducing the learning objectives for the week. The older people did not participate in these lessons. **Two lessons at the end of the day were used for reflecting on LOPP and answering the feedback questionnaires. The older people did not participate in these lessons. ***One lesson each day was allocated to concluding the day together. 

Conclusions

Methods to stimulate discussions

Orientation Group work assignment

Duration of the day Topic of the day

Table 3. Outline of the Learning with Older People Programme (LOPP) (modified from Koskinen et al. 2016)

32 Materials and Methods

Materials and Methods

33

 

4.3. Instruments In this study, three instruments were used to measure outcomes. The Students’ Interest in Nursing Older People Scale (SINOPS) was developed for the purpose of this study, and it was used in both the scoping (I) and the evaluation (IV) phase of the study. Therefore, in this summary SINOPS is described in more detail than the other two instruments, the Kogan’s Attitudes towards Older People scale (KAOP, Kogan 1961) and the Palmore’s Facts on Aging Quiz (FAQ1, Palmore 1977, 1998), which were used only in the evaluation phase of the study (IV). Moreover, Manhardt’s Work Value Inventory (WVI, Manhardt 1972) was used as an independent variable in the evaluation phase of the study. Students’ Interest in Nursing Older People Scale (SINOPS) A new instrument was developed for the study, because no existing instrument for this purpose was found. There are, however, two related instruments that were already in existence. The first of these is a career choice tool, which was used repeatedly in previous studies (Stevens & Crouch 1995). This tool is about a ranking task that requests respondents to place ten nursing specialties in the order of their preference. In addition, there are a number of open-ended questions for commenting on the rankings. The second instrument, Perceptions of Working with Older People (PWOP, Nolan et al. 2002), focuses on working with older people in general, personal disposition towards working with older people and consequences of working with older people. More information beyond the ranking of career alternatives and identifying potential factors related to choosing a career in OPN was desired. Therefore, a new instrument was developed to cover the concept more comprehensively. An inductive approach to the instrument development was used. Conceptual basis of SINOPS To investigate the nursing students’ career plans in OPN, a new concept, interest in older people nursing, was generated. Interest is defined as a) a feeling of wanting to know or learn about something or someone, b) a quality of exciting curiosity or holding attention, or 3) an activity or subject which one enjoys doing or studying (MOT Oxford Dictionary of English). This concept originated and has a long tradition in psychology (Schiefele 1991). Interest as a motivational variable is a directive force. It is able to explain students’ choices in an area in which they strive for high levels of performance or exhibit intrinsic motivation. Interest also refers to a relatively enduring predisposition to re-engage with a certain topic area (object of interest) over a shorter or longer period of time. This type of interest applies to in-school and out-of-school learning and to young and older people alike (Hidi & Renninger 2006, Krapp 1999, Schiefele 1991). Interest has both an affective and a cognitive component. Typically, the affective component describes positive emotions accompanying engagement in a certain topic, whereas the cognitive component refers to perceptual and representational activities related to engagement (Hidi & Renninger 2006, Krapp 1999). Experiencing interest involves an affect from the outset of an encounter. This affect is then combined or integrated with cognition as it develops. As interest develops and is maintained, both affect and cognition contribute to the experience, but the relative strength of the components change over time, and cognition gains an increasing presence (Hidi & Renninger 2006). A person will only engage continuously in a certain topic area if it is assessed, on the basis of cognitive reflections and rational considerations, as being sufficiently important and if the course of interactions on the whole is experienced as positive    

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Materials and Methods

and emotionally satisfactory. Thus, interest is characterised by optimal experiential modes that combine positive cognitive qualities (e.g., thoughts of meaningful goals) and positive affective qualities (e.g., “good mood”) (Krapp 1999). Interest has a powerful influence on a person’s learning (Hidi & Renninger 2006). As a contentspecific concept, interest fits well with the cognitive theories of knowledge acquisition, in that new information is always acquired in particular domains (Schiefele 1991). Rather than being equally interested in everything, individuals are more interested in certain topics, want to learn about (or become involved with) that topic to satisfy that interest (Schiefele 1991). Interest develops between people, resulting in an interactive relationship (Hidi & Renninger 2006, Krapp 1999, Schiefele 1991). The Students’ Interest in Nursing Older People Scale (SINOPS) measures nursing students’ interest in OPN. At the sub-score level, SINOPS tries to explain the factors motivating or discouraging students to pursue this field. At the item level, SINOPS also aims to capture the affective (OPN is joyful.) and the cognitive (There are educational possibilities in OPN.) components of interest. The construct of SINOPS SINOPS is based on the literature review. Its current 54 items (originally 82 items, I) deal with students' interest in OPN and the factors enhancing or decreasing this interest (Table 4). SINOPS consists of a set of 27 items with negatively worded statements and a second set of 27 items with positively worded statements. A mixture of both positively and negatively worded items are intended to minimise the tendency for respondents to blindly agree with a particular statement or respond in the same way to a series of items, which can lead to bias (Rattray & Jones 2007). The Visual Analogue Scale (VAS) was used in measuring. With this scale, students answered each item by marking the point on the 100 mm line that best matched their perceptions (0=strongly disagree, 100=strongly agree). VAS is an interval scale (Foley 2008, Waltz et al. 2010). It is able to determine even subtle changes because of the great range of possible scores. It can also be used for smaller sample sizes and allow more powerful parametric statistical analysis, as the data are more likely to be normally distributed than with categorical scales (Celenza & Rogers 2011). Furthermore, VAS is useful for measuring possible changes over time in a particular individual (Waltz et al. 2010). Five sum variables were decided upon, based on the literature review, and included 1) a willingness to work in OPN, 2) characteristics of OPN, 3) valuing OPN, 4) the quality of OPN and 5) challenging aspects of OPN and opportunities for career advancement (Table 4). To be able to correctly interpret the scores, the scores for the negatively worded items had to be reversed. The total and sum scores were calculated by summing up the values for each answer and dividing the sum by the number of items. The range of the total and sum scores was the same for each single item ranging between 0 and 100, with higher scores indicating more interest in OPN and more interest enhancing factors.

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  Table 4. Structure and statements of the Students’ Interest in Nursing Older People Scale (SINOPS) Willingness to work in OPN (Willingness) Positive statements Negative statements I am interested in working in OPN right after I am not interested in working in OPN right after graduation. graduation. I will possibly work in OPN later on my career. I do not want to work in OPN in any phase of my career. I am interested in working in outpatient care (e.g., I am not interested in working in outpatient care (e.g., home health care). home health care). I am interested in working in inpatient care (nursing I am not interested in working in inpatient care home, health centre ward). (nursing home, health centre ward). I knew already when applying that I want to work I knew already when applying that I want to work in in OPN. other fields than OPN. My interest in OPN has increased as studies have My interest in OPN has decreased as studies have progressed. progressed. Characteristics of OPN (Characteristics) Positive statements Negative statements OPN is developing. Old-fashioned practices still strongly exist in OPN. I do not want to work with terminally ill older I want to work with patients expected to fully people. recover. I regard encountering death as a natural part of I do not want to work with older people close to nursing. death. OPN is challenging. OPN is boring. OPN is comprehensive. OPN focuses on single actions. OPN is joyful. OPN is sad. I experience pleasure when working in OPN. OPN is depressing. OPN is not physically taxing. OPN is physically taxing. Valuing OPN (Valuation) Positive statements Negative statements OPN is valued in Finland. OPN is not valued in society. Nurses working in OPN are valued among other Other nurses do not value nurses working in OPN. nurses. Quality of OPN (Quality) Positive statements Negative statements Nurses behave respectfully towards older people. Nurses have negative attitudes towards older people. Nurses in OPN are enthusiastic. Nurses in OPN have low motivation. There is good team spirit in OPN wards. There is poor team spirit in OPN wards. There is no sense of hurry in OPN. There is a sense of hurry in OPN. There is an adequate amount of staff in OPN. There is shortage of employees in OPN. There are good learning experiences available in There are no good learning experiences available in OPN. OPN. Challenging aspects of OPN and opportunities for career advancement (Career) Positive statements Negative statements OPN requires special competence. In OPN no special skills are required. There are possibilities for fulfillment in OPN. OPN is routine-like. There are educational possibilities in OPN. OPN is the end of a career. The responsibility due to the independence of nurses The responsibility due to the independence of nurse in OPN is rewarding. in OPN is frightening. Regular continuing training is required in OPN. Everything necessary to practise OPN can be learned in single clinical training.

   

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Materials and Methods

Attitudes towards Older People scale (KAOP) KAOP measures attitudes towards older adults (Kogan 1961). It is a 34-item scale including a set of 17 items with the statements worded negatively (KAOP-) and a second set of 17 items with the statements worded positively (KAOP+). KAOP is a Likert-type scale, measuring attitudes using six response categories (1=strongly disagree, 7=strongly agree), with a neutral score of four assigned in cases of a failure to respond to an item. To obtain the total KAOP score, scores for the negatively worded items must be reversed. The total score ranges between 34 and 238. Higher total scores indicate more positive attitudes (Kogan 1961). The KAOP+ and KAOP- scores range between 17 and 119. Higher scores for KAOP+ and lower scores for KAOP- indicate more positive attitudes. Validation studies conducted in several countries have demonstrated a good reliability level (Yen et al. 2009, Matarese et al. 2013). KAOP continues to be the most commonly used instrument despite some concerns about its current relevancy (Neville 2015). Facts on Aging Quiz (FAQ1) FAQ1 assesses the knowledge level of physical, psychological, social and economic factors related to ageing and misconceptions about older people (Palmore 1977, 1998). FAQ1 consists of 25 questions with possible answers of “true”, “false” or “don’t know”. The total score ranges from 0 to 25. Higher scores reflect higher knowledge levels about ageing. To calculate the total score, a “true” response is assigned one point and “false” and ‘‘don’t know’’ responses are assigned zero points. The FAQ1 has been validated internationally, and it has been proven to be reliable (Wang et al. 2010, Zisberg et al. 2015). Feedback questionnaire concerning LOPP Both the older people and nursing students were requested to give feedback on LOPP using structured questionnaires developed for this purpose. The older people’s questionnaire contained background questions, one open-ended question requesting the respondent’s reasons for participating in LOPP, one five-point Likert-scaled (1=extremely poor, 5=extremely good) question about their participatory experience, and a further open-ended question requesting the grounds for the given rating. The students’ questionnaire contained two general VAS-scaled (0=not useful at all, 100=extremely useful) questions concerning 1) LOPP as a whole and 2) impressions about the older people’s involvement in the teaching from the point of view of the learning process, 14 focused five-point Likert-scaled (1=totally disagree, 5=totally agree) questions about LOPP, and two open-ended questions concerning 1) the best qualities of LOPP and 2) how LOPP could be developed. Work Values Inventory (WVI) WVI was used as a background, not outcome, instrument. It measures work values by requesting respondents to indicate how important it is to them to have a job with certain characteristics (Manhardt 1972). The scale consists of 25 job characteristics to rate on a fivepoint scale (1=not important, 5=very important). There are three general categories: Comfort and Security, Competence and Growth, and Status and Independence. Scores for each category are calculated by summing and averaging items in each factor. WVI has been tested for its reliability among college and university students and graduates from various fields, and has been found reliable (Leuty 2010, Takase et al. 2005, Meyer et al. 1998, Manhardt 1972).

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4.4. Data analysis In the both phases of the study, various analysis methods were used. Statistical analyses Statistical methods were used for the analysis of the structured data (Table 5). In the scoping phase, the data was analysed using Statistical Package for the Social Sciences (SPSS) 16.0 software, and Statistical Analysis System (SAS) software (version 9.3 Inc, Cary, NC, USA) was used for the evaluation phase. Both descriptive and inferential statistics were used. Descriptive statistics were used to communicate the information about study samples and the values of the dependent variables. The analyses began with examining frequency distributions, central tendencies and variabilities in order to organise the data and clarify patterns. Inferential statistics were used to estimate population parameters from sample statistics. Mainly, the parametric tests were used, as the amount of observations supported the choice of the parametric statistical tests, and the data were, for the most part, normally distributed. For all tests, the level of statistical significance was set at p≤0.05. The differences between the means of the two groups were tested with the t-test when the dependent variable was on interval scale. The t-test was used for comparison of two independent groups (e.g., IGs and CGs), and a paired t-test for examining within group changes (e.g., prepost-test scores for the CG). As an extension of a paired t-test, repeated measures analysis of variance (RM-ANOVA) were used when there were multiple means being compared over time (comparison within IG). The chi-square test was used to test group differences in proportions by comparing observed frequencies and expected frequencies when the dependent variable was categorical. For small cell sizes, Fisher’s exact test was used. Confidence intervals were constructed around the difference between two means and proportions providing information about both the statistical significance and the precision of the estimates. The magnitude of two-variable relationships was tested with the Pearson’s correlation coefficient when the variables were on an interval scale. Spearman’s correlation coefficient (r) was used for ordinal level variables or when the distribution of the variable was skewed. Analysis of covariance (ANCOVA) was used to control for confounding variables when comparing the means of two groups. ANCOVA was proved to be useful, as in the nonequivalent comparison group design, the influence of preexisting group differences on the obtained results needs to be considered. ANCOVA adjusts for initial differences so that the results more precisely reflect the effect of an intervention. Multivariate linear modeling (or regression analysis) was used to find associations between a continuous dependent outcome variable (SINOPS total, KAOP total, FAQ1) and several independent variables. To assess the strength of the relationship between the dependent outcome variable and the several independent variables, multiple correlation coefficients (R) were used. The squared R statistic (R2) was calculated to indicate the proportion of variance in the dependent outcome variable accounted for by the combined, simultaneous influence of the independent variables. The test for the significance of this equation, principles analogous to those for analysis of variance (ANOVA) was based on the examination of the means. Regression coefficients (betas) assessed the relative importance of each independent variable.      

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Materials and Methods

Table 5. Summary of the statistical procedures used in different phases of the study Phase Scoping

Sub-study I IV

Evaluation Summary

Data analysis Descriptive statistics, t-test for independent samples, Spearman’s correlation coefficient Descriptive statistics, Chi-Square, Fisher’s exact test, t-tests for independent and paired samples, RM-ANOVA, ANCOVA t-tests for independent samples, Pearson’s and Spearman’s correlation coefficients, multivariate linear modeling

Narrative analyses Inductive analysis methods – qualitative content analysis (Graneheim & Lundman 2004) and thematic analysis (Braun & Clarke 2006) – were applied for all textual data generated in this study, that is the scoping literature review (II), the document analysis (III) and the open questions of the post-intervention survey (V). Qualitative content analysis and thematic analysis share many similarities (Vaismoradi et al. 2013). However, the thematic analysis method was regarded more suitable for analysing the Finnish society’s attitudes towards older people based on the newspapers (III), as the thematic analysis is considered to emphasise the context of the data (Vaismoradi et al. 2013). For other studies (II, V), qualitative content analysis was chosen. The data analysis process in both of the analysis methods is rather equivalent (Vaismoradi et al. 2013, Braun & Clarke 2006, Graneheim & Lundman 2004). In all of the studies (II, III, V), the researcher herself concentrated on the initial analyses, becoming familiar with the data at an in-depth level, and maintaining a sense of the broader picture. For validity purposes, a research group was involved in later phases of the analyses. Depending on the study, either manifest (II) or latent (III, V) content were analysed. The analyses started with coding. The coding process was conducted incident by incident, using words from the raw data to stay close to the original expressions. Next, the coded data extracts containing aspects related to each other were condensed and grouped together, based on their similarities, into either subcategories (II, V) or basic themes (III), depending on the analysis method used in the study. These subcategories or basic themes were then combined into categories or organising themes, and finally abstracted as overarching categories or universal themes. Generating and reviewing the categories and the themes was an iterative process, requiring movement back and forth between the coded data extracts and the categories and themes.

4.5. Ethical considerations This research followed good research ethics throughout the research process, from the selection of the research topic to the publishing of the results (Finnish Advisory Board on Research Integrity TENK 2012, European Science Foundation and ALL European Academies 2011, ETENE 2001). From the ethical point of view, this research addressed three major topics. First, this research is justified, as it addresses the need for more competent nurses to take care of older people. Ultimately better nursing care for older people could be expected if more enthusiastic, competent and motivated nurses would seek their way to the field (ETENE 2008). Secondly, this research promotes an increase in older people involvement in society, as it highlights examples of older people actively being a part of nursing education. Thus, this study includes those voices which need to be heard: the ones which will most likely be, at some point, the recipients of care (Ministry of Social Affairs and Health 2013, WHO 2002). Thirdly, as nursing education needs more research to develop the evidence on which curricular and

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programmatic decisions are made, this study provides discipline-specific evidence for evaluation and further development, to determine the most effective means of nursing education which have been repeatedly called for (Salminen et al. 2010, Ridley 2009, Ferguson et al. 2006). Research integrity Ethical approval for the evaluation phase was received from the Ethics Committee of the University of Turku (Statement 5/2014, 10.2.2014). In both phases, permission to conduct the study was obtained from each of the polytechnics, according to their policies. Permission to use and translate the scales was received from the scales’ copyright holders. The research was explained to all study participants in an information letter and also verbally, by the researcher. First, a brief recruitment statement was presented, explaining the study’s purpose, what it would entail, the confidentiality procedures and contact information. Then, participants were told what contributions to nursing education the researcher hoped to make, and that possibly, the study would not actually benefit the participants themselves. All research participants were assured that nonparticipation, or withdrawal from the study at any time, would result in no penalty (European Science Foundation and ALL European Academies 2011, Bradbury-Jones & Alcock 2010, Ridley 2009). In the scoping phase, students gave their informed consent by answering the questionnaire (I). In the evaluation phase (IV, V), students volunteering to participate in the study were asked to sign a consent form and were given a copy to keep for their personal records. Similarly for older people, a written statement of informed consent was requested on the first day they attended LOPP. If they participated several days, consent was confirmed orally each day. The researcher demonstrated genuine gratitude to all participants and made the benefits of participation clearly known to them. After students gave their consent to participate in the study, they were verbally thanked for participating and were offered sweets (I, IV, V). To prevent students from dropping out in the evaluation phase, a lottery was arranged for participants in both the IG and the CG (Ridley 2009). The prize was a gift voucher to a bookshop. The confidentiality of the research participants was maintained by assigning code numbers to all collected data. Further, the polytechnics could not be identified based on the results, and no comparisons between them were done. For the evaluation phase (IV), a coding list was created, linking a code number to each nursing student’s identity, so that each participant’s responses from different times of data collection could be linked together for analysis. The coding list was kept separate from the research data, in a file accessible only to the researcher. Encoded electronic data were kept on a firewalled network, accessed only with a password, and updated anti-virus protection. Paper questionnaires were kept together in a locked file cabinet and will be eventually destroyed (Ridley 2009). Nursing students as research participants Nursing students were the main research participants in both phases of the study (I, IV, V). Nursing students are not considered a highly vulnerable research group, as such, because they are adults and are able to give their informed consent. However, the power difference between nursing students and their instructors requires ethical sensitivity when conducting education research. This power relationship is based on the differences in knowledge, skills and attitudes    

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in the profession of nursing as well as the social contract that exists when students are admitted to an educational programme. It is further emphasised when instructors have evaluative roles in grading student achievement and making decisions about their progress in the programme. Thus, students’ vulnerability in relationships with their instructors may limit their abilities to consent voluntarily (Bradbury-Jones & Alcock 2010, Ridley 2009, Ferguson et al. 2006). In these cases, students may be at risk of feeling that their course grades are tied to their research participation, or lack thereof, even if they are assured otherwise. However, in neither phase of this study was the researcher involved in the academic evaluation of the students. The researcher was not a member of staff at either participating polytechnic. Further, the researcher met the students for the first time when she recruited them to participate in the study. Therefore, it is assumed that students did not feel uncomfortable with participating in the study (Ridley 2009), as they had no previous relationship with the researcher. Even so, some students may have agreed to participate in order to please the researcher, as she was a researcher/instructor, although this might not necessarily mean that they felt overtly coerced (Bradbury-Jones & Alcock 2010). For the evaluation phase, LOPP was regarded as a mandatory part of the existing curriculum, and thus, it was compulsory for students to participate in the programme. Although LOPP was designed to be a new, beneficial approach to learning about older people, it was thought students in the CG could also prosper from learning about OPN (Ferguson et al. 2006). As in the CG, research participation in LOPP was voluntary, and students in the IG had the opportunity to not respond to the questionnaire (Ridley 2009). Most likely, students felt free to refuse to participate and did not fear that the refusal would in any way affect their academic progress or subsequent learning experiences. Nursing students were verbally encouraged to respond honestly according to their opinion when asked about their experiences regarding LOPP. It was pointed out that the researcher would value truthful positive experiences as well as development ideas. Further, students were assured that they need not fear that unenthusiastic or disapproving responses would affect them in any way (Ferguson et al. 2006). The one-month follow-up data collection was scheduled for a class in which participation was not compulsory but highly recommended. Some students were absent and were therefore approached individually by posting the questionnaire and return envelope to them. Older people in LOPP Older people should have opportunities to participate in research. Increasing the participation of older people in research will improve the generalisability of research findings and reveal best practices in the clinical care of the growing older population. First of all, as a matter of human rights, just as with any human research subjects, older people have a right to be involved in research that is aimed to have an impact to their care. Secondly, to produce findings that may possibly contribute to the quality of life of older people or the services for them, it is essential to involve them so that they can contribute their own understandings about ageing and service (Walker 2007). Older people were recruited via telephone and face-to-face contact. It was of primary importance that provided information was in a language that was readily understood. Sophisticated research terminology that older people might not understand and that may obviously undermine the process of informed consent was avoided, but at the same time, balanced with the risk of it being insufficiently simplistic or patronising. For recruiting, time, space and a safe environment was provided for participants to ask questions about LOPP and the current research. This also provided an opportunity for the researcher to assess participants’

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understanding. After initial contact, the older people were given time to consider whether they wanted to participate in LOPP or not. About a week preceding LOPP, the researcher recontacted the older people who had tentatively agreed to participate, to confirm their inclusion in LOPP. Telephone numbers and permission to call were requested orally at the first contact. During LOPP, it was essential to secure the well-being of the older people. Considering physical well-being, older people were not exposed to any manipulative or invasive nursing treatments, and they were insured for accidents, such as falling. They were requested to share personal health data and reflect on life events and their experiences of ageing. This could be emotionally stressing, but they were allowed to regulate and decide for themselves what information they wanted to share with the students. They were not required to relate anything they did not wished to. To be able to ensure the emotional well-being of older people, at the end of each day, they were encouraged to stay after the class and reflect on their experiences of the day with the researcher. This provided an opportunity to for them to unburden themselves, if something happened to be bothering them.

   

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5.

Results

RESULTS

The results are presented according to the study phases, following the research questions. First, the results of the different premises (I, II, III) for nursing students’ to choose a career in OPN are described. After that, nursing students’ the actual choice of a career in OPN is described (IV, V).

5.1. Premises for nursing students’ choice of a career in older people nursing In this study, the premises for nursing students’ choice of a career in OPN were seen to be nursing students’ interest in OPN (I), Finnish society’s attitudes towards older people (II) and main research areas in the education of OPN (III). 5.1.1. Nursing students’ interest in older people nursing (I) Nursing students’ interest in OPN was determined based on their self-reported answers to SINOPS. Generally, based on results, the interest of nursing students in OPN was not clear, and variation existed between students. The background variables that were found to be consistently related to interest included prior nursing work experience and having taken an independent OPN course. The sub-score of SINOPS measuring nursing students' willingness to work in OPN was approximately in the middle of the VAS (Willingness mean 45.05, SD 22.70). In regards to the other sub-scores, the quality of (Quality mean 72.25, SD 18.12) and challenging aspects of OPN and opportunities for career advancement (Career mean 64.02, SD 14.28) enhanced students’ interest in OPN. The low valuing of OPN decreased students' interest (Valuation mean 31.82, SD 18.52). The characteristics of OPN did not distinctly enhance or decrease student interest in OPN (Characteristic mean 55.13, SD 12.28). Students who had prior work experience (p